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February 10, 2020

Can We Really Stop Pediatric Migraine?Using Network Meta-analysis to Remove the Guess Work

Author Affiliations
  • 1Children's and Adolescents' Hospital Datteln, Witten/Herdecke University, German Paediatric Pain Centre, Datteln, North Rhine-Westphalia, Germany
JAMA Pediatr. 2020;174(4):325-326. doi:10.1001/jamapediatrics.2019.5907

Pediatric primary headache is one of the leading health care issues in high-income countries that is rising in prevalence.1 Frequent headaches are strongly associated with a lower quality of life and poorer academic performance and are a leading cause of school absence.2 The classification system of the International Headache Society provides a navigation system to phenomenologically diagnose migraines, tension-type headaches, and other primary headaches (https://ichd-3.org/wp-content/uploads/2018/01/The-International-Classification-of-Headache-Disorders-3rd-Edition-2018.pdf); however, pediatric-specific factors have not been considered sufficiently.3

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    2 Comments for this article
    Pediatric Migraine
    Dan Spearman, MD | Private Practice
    Despite the fact that cyproheptadine has been felt to be a non-starter as the first choice for pediatric migraine, I find that in younger patients it seems to lessen the frequency and severity of the headaches, followed by amitriptyline if no improvement. I disagree that nothing helps, just from my own experience over the years.
    Could pediatric migraine be cause by breath-holding?
    Richard Schmidt, BPharm PhD | Retired pharmacist
    Although never formally diagnosed as pediatric migraine, I suffered such headaches during my school years in the 1960s, usually on Tuesdays and Thursdays, as I recall. The only "cure" was to wait for vomiting to occur, and then sleep. Acetaminophen prescribed by my general practitioner did nothing other than perhaps hasten vomiting.

    Later in life, these became my "Monday headaches", usually starting mid-afternoon. For some time, I believed that these headaches were a symptom of a food intolerance or perhaps related to air-quality at work (in a University building), but could never properly identify a trigger.
    Then on one particular Monday, I did not have a headache. The difference was that on the Sunday prior to that Monday I had engaged in vigorous sport (a league badminton match at an away venue).

    So, as I had some Multitest urine-testing strips available, I tested my urine when I next developed migraine symptoms. The only significant abnormal test was urine pH, which showed a more alkaline reaction than normal, indicative of bicarbonate excretion. This alerted me to the possibility that my migraines were being caused by a failure to breathe properly, thereby failing to "excrete" carbon dioxide via the lungs, forcing its excretion via the kidneys. In other words, my migraine headaches were analogous to altitude sickness.

    With this new understanding, I deliberately on Sunday evenings carried out breathing excercises with long, forced exhalations with a view to forcing excretion of carbon dioxide via the lungs. I have not suffered a migraine headache since I started using this strategy. The reason why I was not breathing properly is because I would regularly carry out home renovation work during week-ends, this often being a dusty process ... and I found working with a mask difficult because my spectacles would mist over!

    An alternative treatment might be to administer acetozolamide. I had discussed this possibility with my general practitioner in the 1990s. We were planning to write this up as a case report but never did before I moved away and she retired.

    Having worked as a pharmacist for over 40 years, I have on several occasions repeated this anecdote to adult patients suffering migraines ... and received positive feedback of successful avoidance of migraines. And I wonder whether the use of acetozolamide as a migraine treatment has ever been trialed?